Mesh Versus Suture Cruroplasty in Hiatal Hernia Repair: Recurrence, Safety, And Current Controversies in Patients Underwent Sleeve Gastrectomy

Abstract

Hiatal hernia repair, particularly in large or recurrent cases, represents a major surgical challenge. Despite advances in minimally invasive surgery, the optimal technique for crural closure remains debated. The central controversy lies in whether mesh reinforcement offers superior long-term outcomes compared with suture-only cruroplasty. Suture cruroplasty is a surgical technique in which the diaphragmatic crura are approximated and closed using sutures alone, without the use of prosthetic material, thereby restoring the hiatal opening in a physiological manner. Mesh cruroplasty, in contrast, combines suturing of the crura with reinforcement using a mesh, which may be synthetic or biologic, to provide additional support and reduce the risk of recurrence, particularly in large or recurrent hiatal hernias. While mesh use may reduce short-term recurrence rates, concerns persist regarding mesh-related complications, durability, and patient safety. Synthetic non-absorbable meshes offer durable reinforcement and lower recurrence rates, especially in large defects, but carry risks such as erosion, stricture formation, and dysphagia. Conversely, absorbable and biologic meshes aim to provide temporary support during tissue remodeling, potentially reducing long-term complications, although long-term efficacy data remain limited. Current evidence suggests that mesh reinforcement may be advantageous in selected patients with large defects, recurrent hernias, or weak crural tissue. However, routine mesh use remains controversial because of the low quality of available evidence and the potential for serious delayed complications.